REACH-B REACH-B: Advice – Online FormPlease provide patient case information using the form below and a specialist will be in touch to provide support within 48 hours. You are welcome to use the form multiple times for different cases or questions. You will receive a PDF of the completed form to your email upon submission. Patient data is de-identified and collected for the REACH-B Study. * Indicates required field Please ensure that no identifying patient information is included in your submission and that patient confidentiality is maintained.Date of request* DD slash MM slash YYYY HBV s100 Prescriber informationPrescriber name*Prescriber phone number (mobile)*Prescriber email address* Please use a personal email address NOT a general clinic email Would you prefer to be contacted via: Email Phone Please note: if we are unable to contact you by phone we will send an email responseClinic NamePrescriber phone number (clinic)Prescriber postcode*Patient/case detailsPatient Initials*Date of birth* DD slash MM slash YYYY Gender* Male Female Non-Binary Transgender Male (assigned female at birth) Transgender Female (assigned male at birth) Patient prefers not to disclose Differently described, please specify Interpretation of blood results and normal ranges can change depending on a person’s gender/sex.Differently described, please specifyCountry of birth*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsIs there any other background about this patient that would be important to be aware of? (For example: Cultural Background, Medicare eligibility, etc.)Serology and clinical informationPlease advise on results of most recent testsHBsAg* Positive Negative Not done anti-HBc* Positive Negative Not done anti-HBs Positive Negative Not done HbeAg* Positive Negative Not done HBV DNA (viral load)*Please enter a number ALT (U/L)* ALT Upper limit of normal*AST (U/L)*AST Upper limit of normal (for the pathology service)*Please enter a number less than or equal to 99.Platelets (10^9/L)*APRIDoes the patient have cirrhosis?* Yes No Unknown Elastography (e.g Fibroscan) Assessment score (if available)i.e., Fibroscan or similarLiver ultrasound (if available)Were these tests done in the last 12 months?* Yes No If not, please consider ordering updated serology or imagingWhat previous HBV regimens (select all that apply if patient had multiple HBV treatments)* None Pegylated Inteferon Lamivudine Adefovir Tenofovir disoproxilfumerate (TDF) Tenofovir alafenamide (TAF) Entecavir Emticitabine (FTC) Descovy Truvada Other Other treatment regimen, specify*Current HBV regimen (select all that apply)* None Pegylated Inteferon Lamivudine Adefovir Tenofovir disoproxilfumerate (TDF) Tenofovir alafenamide (TAF) Entecavir Emticitabine (FTC) Descovy Truvada Other Other current treatment regimen, specify*Does your enquiry relate to?* Treatment initiation support Ongoing monitoring support Isolated anti-HBc positive Suspected HCC and/or other HCC enquiries What tests to order Pregnancy and hepatitis B Cancer and hepatitis B Stopping hepatitis B medication Drug interactions Immunosuppression in the context of previous infection and core antibody positive Other Please provide details of this case*If available, please consider including information on/results: Co-infection (Hepatitis C, HIV, Hepatitis D) and current management of this; Any assessment of liver disease: APRI if available, Fibroscan and/or Liver ultrasound; If relevant: anti-HBc IgM = positive/negative; All other relevant context and information.Is there any further clinical information that would be relevant?Please consider including information on: Other relevant blood test results including FBE, LFT & INR; Patients’ BMI; Any other comorbidities Any relevant family history (especially HCC); List of current medicationsWhat advice are you seeking?What phase of infection is this patient in?* HBeAg-positive chronic infection (Immune tolerance) HBeAg-positive chronic hepatitis (Immune clearance) HBeAg-negative chronic infection (Immune control) HBeAg-negative chronic hepatitis (Immune escape) Unsure Would you suggest that this patient should be commenced on treatment?* Yes No Unsure If yes, what medication would you wish to prescribe?* Tenofovir Entecavir Unsure Is there anything further you would like to add about your treatment plan for this patient?What is your plan for ongoing monitoring?*Does this patient require HCC surveillance?* Yes No Unsure What will this include? Liver ultrasound AFP (blood test) Other Not sure Multiple options availableHow often would you do HCC surveillance? 3 monthly 6 monthly Yearly Not sure Is there anything else you would like to add?Additional filesPlease attach any supporting information that might be useful such as pathology results, imaging, case notes etc. Please note: these must be de-identified and not contain any identifiable patient information.Upload a fileAccepted file types: jpg, png, pdf, Max. file size: 5 MB.EmailThis field is for validation purposes and should be left unchanged.
